ACUTE RESPIRATORY INFECTIONS

- Most common human ailment.

- It increases the morbidity and mortality rates in young
infants, small children and in the elderly, or in persons
with impaired respiratory tract reserves.
- Classified by clinical syndromes depending on the site of
infection – (i) Acute Upper Respiratory Infection(AURI)
(ii) Acute Lower Respiratory Infection(ALRI).
- AURI includes common cold, pharyngitis and otitis media.
- ALRI includes epiglotitis, laryngitis, laryngotracheitis,
bronchitis, bronchiolitis, pneumonia.
- The clinical features include running nose, fever, cough,
sore throat, difficult breathing and ear problem.
- Pneumonia Continues to kill more children under five
worldwide than any other single infectious disease
claiming an estimated 0.80 million children’s life in 2018.
- Young children are at high risk and nearly 80% of death
associated with pneumonia occurs at the first two years of
life.
- Streptococcus Pneumoniae is the major cause of illness
and death in children.
EPIDEMIOLOGICAL DETERMINANTS:

AGENT FACTORS:
- Microbial agents that cause ARI are numerous and includes
bacteria and viruses and even within the species they can show
wide diversities of antigenic type.
- Bacteria - Streptococcus Pneumoniae, Klebsiella pnuemoniae,
Staphylococcus pyogenes, Bordetella pertussis(Causes paroxysmal
cough).
- Viruses – Influenza A,B,C , Adenovirus, Enterovirus(ECHO and
Coxsackie), Measles.
- Other agents like Chlamydia Type B, Coxiella burnetti(Q fever)

HOST FACTORS:
- Small Children succumb to the the disease within a matter of
days.
- Fatality rates are higher in young children and malnourished
children
- Malnutrition and low birth weight are major problems in
developing countries.
- Incidence of AURI are several times higher in children (especially
blow the age of 5 years) than in adults.
- The greater exposure of women to small children may be
responsible for this.
- Under 3 years of age boys are affected more often and more
severely.

RISK FACTORS:
 - Climatic conditions, Housing, Level of industrialization and Socio
economic development are some of the risk factors of respiratory
tract infections.
- Overcrowded dwellings, poor nutrition, Low birth weight, and
intense indoor smoke pollution underline the high rates.
- Local mortality rates are particularly affected by extent of
influenza epidemics.
- Infections are more common in urban communities than in rural
communities.

MODE OF TRANSMISSION:
- Airborne route of transmission.
- Chain of transmission is maintained by direct person-to-person
contact.
- CONTROL OF ACUTE RESPIRATORY INFECTIONS
*Improving the primary medical care services and
developing better methods for early detection, treatment and
prevention – Effective treatment for Pneumonia can reduce the
mortality rate in children.

CLINICAL ASSESSMENT:
- History taking and management are important in the
management.
- Note the age of the child, for how long the child is coughing,
whether the child is able to drink, has the young infant stopped
feeding well, has there been any antecedent illness such as
measles, does the child have fever, is the child excessively drowsy
or difficult to wake, did the child have convulsions, is there
irregular breathing, short periods of not breathing or the child
turning blue, any history of treatment during the illness.
PHYSICAL EXAMINATION:
1. Count the breaths in one minute – as the child get older the
breathing rate gets slower. Increased respiratory rate is
significant only if it persists. Fast breathing is present when
the respiratory rate is,
*60 breaths per minute or more in a child less than
2 months of age
*50 breaths per minute or more in a child aged
2 months upto 12 months
*40 breaths per minute or more in a child aged
12 months upto 5 years.
2. Look for chest indrawing – The child will have chest
indrawing if the lower chest wall goes in when the child
breathes in. This occurs when the effort required to breathe in
much greater than the normal.
3. Look and listen for stridor – The child with stridor will make
a harsh noise when breathing in – this is due to narrowing of
larynx, trachea or epiglottis which interferes the air entering
the lungs.
4. Look for wheeze – The child with wheeze makes a soft
whistling noise or show the signs of difficulty breathing out –
this is due to narrowing of air passage in lungs – if the child
has wheezing ask the mother if the child had any previous
episodes of wheezing within past year, if so the child should be
classified as having recurrent wheeze.
5. Abnormally asleep or Difficulty to wake the child.
 6. Fever or low body temperature.
7. Check for severe malnutrition – child with severe malnutrition
may have an impaired or absent response to hypoxia and a
weak or absent cough reflex – fast breathing and chest
indrawing may not be evident in malnourished than in other
children.
8. Cyanosis – Sign of hypoxia.


A) CHILD AGED 2 MONTHS UPTO 5 YEARS
B) YOUNG INFANTS UNDER TWO MONTHS OF AGE
A) Child aged 2 months upto 5 years :
 Children(2-59 months) with Chest indrawing/fast breathing pneumonia and
without general signs of danger is treated with oral amoxicillin – at least
40mg/kg/dday for five days. (If the first line treatment is failed the children
should have the option of referral to a facility where there is appropriate
second line treatment)
 Children(2-59 months) with Severe pneumonia is treated with Parentral
ampicillin(50mg/kg, or benzyl penicillin – 50,000 units in IV/IM for every
5hrs for atleast 5 days)(or oral penicillin) and gentamycin(7.5mg/kg/day
IM/IV for 5 days) as first line treatment. (If the first line treatment is failed
the children is given Ceftriaxone as second line treatment)
 Ampicillin + Gentamycin or ceftriaxone is the first line regimen for HIV
infected and HIV exposed infants.
 Empiric Cotrimoxazole treatment for suspected Pneumocystis jirovecii
pneumonia(PCP).(Not given for HIV infected patients and patients with
severe pneumonia)
 Cough and cold –
No Pneumonia Home care advice
Child aged
2-59
months Fast breathing Oral amoxicillin
and/or chest
with cough and Home care
indrawing
and/or Pneumonia advice
difficulty in
breathing
First dose antibiotic
General danger and referral to facility
signs – severe for injectable
Pneumonia or very antibiotic / supportive
severe disease therapy

B) Young infants under 2 months of age :

FREQUENCY
ANTIBIOTIC DOSE AGE AGE
< 7DAYS 7 DAYS –
2 MONTHS
Inj.Benzyl penicillin 50,000 IU/Kg/dose 12 hourly 6 hourly
OR
Inj. Ampicillin 50mg/kg/dose 12 hourly 8 hourly
AND
Inj. Gentamycin 2.5mg/kg/dose 12 hourly 8 hour;y

 NOTE – Patients with only AURI and no Pneumonia does not

require antibiotic treatment – Symptomatic treatment and Care
at home is generally enough
 PREVENTION OF ARI:
 Improving living conditions
 Providing better Nutrition
 Reduction of smoke pollution indoors
 Better MCH care
 Immunization (Especially for measles )
 Health promotional activities
IMMUNIZATION:
 Measles Vaccine
 Haemophilus influenzae type B (Hib) Vaccine –
6,10,14th week and booster dose is between 12-18
months.
 PNEUMOCOCCAL PNEUMONIA VACCINE:
- PPV23:
*Polysaccharide non-conjugate vaccine containing
capsular antigen of 23 serotypes.
*Recommended for selected groups – Those who have
done splenectomy or patients with sickle cell disease, Chronic
liver disease etc..
*IM (Deltoid) or Sub-cutaneous administration - vaccine
should not be mixed with same syringe of other vaccine –
Simultaneous administration does not have increased adverse
effect of decreased antibody response.
 - PCV:
+ Two conjugate vaccines are available since 2009 PCV10 and PCV13 •

+ Both PCV10 and PCV13 are preservative free and their recommended
storage temperature is 2-8°C. The vaccine must not be frozen
+ For PCV administration to infants, WHO recommends 3 primary doses
(the 3p+0 schedule) or, as an alternative, 2 primary doses plus one booster (the 2p +
1 schedule).
+ In 3p+ 0 schedule, vaccination can be initiated as early as 6 weeks of age
with an interval betweeen doses of 4-8 weeks, with doses given at 6, 10 and 14
weeks or 2, 4, and 6 months, depending on programme convenience.
+ If 2p+ 1 schedule is selected, the 2 primary doses are given during infancy
as early as 6 weeks of age at an interval preferably of 8 weeks or more for young
infant, and 4- 8 weeks or more between primary doses for infants >7 months
of age. One booster dose should be given between 9- 15 months of age.
+ HIV positive and preterm babies who have received their 3 primary doses
of vaccine before reaching 12 months of age may benefit from a booster dose in the
second year of life.
+ Interrupted schedules should be resumed without
repeating the previous doses.
The Integrated Global Action Plan for the
Prevention and Control of Pneumonia and
Diarrhoea:
- The Integrated Global Action Plan for the Prevention and Control of
Pneumonia and Diarrhoea (GAPPD) proposes a cohesive approach to
ending preventable pneumonia and diarrhoea deaths
*The specific goals for 2025 are to:
- reduce mortality from pneumonia in children less than 5 years of
age to fewer than 3 per 1000 live births,
 - reduce mortality from diarrhoea in children less than 5 years of
age to fewer than 1 per 1000 live births,
- reduce the incidence of severe pneumonia by 75% in children less
than 5 years of age compared to 2010 levels,
- reduce the incidence of severe diarrhoea by 75% in children less
than 5 years of age compared to 2010 levels,
- reduce by 40% the global number of children less than 5 years of
age who are stunted compared to 2010 levels.
*By the end of 2025:
- 90% full-dose coverage of each relevant vaccine (with 80%
coverage in every district),
- 90% access to appropriate pneumonia and diarrhoea case
management (with 80% coverage in every district) ,
- at least 50% coverage of exclusive breast-feeding during the first 6
months of life;
- virtual elimination of paediatric HIV.

* By the end of 2030:

- universal access to basic drinking-water in health care facilities and
homes,
- universal access to adequate sanitation in health care facilities by
2030 and in homes by 2040,
- universal access to handwashing facilities (waterand soap) in health
care facilities and homes,
- universal access to clean and safe energy technologies in health care
facilities and homes.